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HomeMy WebLinkAbout11818 CITY OF DIAMOND BAR �� DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES fg, . � 21660 E.Copley Drive Suite 19p �� (909)860-3195 Fax(909)861-3117 PRESS �"9f"� � BUILDING PERMIT APPLICATION FIRMLY � JOBSITE �/���� �L��n � APPLICATION f n PERMIT P/C � ADDRESS_ "'( 1JL ri DATE �Y � NUMBER # �� � ISSUE TYPE OCC APN LOT TRACT DATE CONST.__ GROUP � OWNER �I �C-�C �-x�1rc�Y1C�Y ADDRESS�4�_C� ZONING SETBACKS � CITY��j{�ZIP I��l ` TEL. °E,Q�I� FRONT RW ❑ — APPLICANT R.C11'1C,I111f': C,fsk4'Y' TEL.�' b � SI�SIDESTREET RW I I � CONTRACTOR SIDE ❑ � ADDRESS�• �• � CITY AL��R �C..`YY►'F3___ ZIP `�I�� TEL.� �^�aY,�(; PROPOSED USE oARCH/ENG/ z DESIGNER a ADDRESS NO.DWEL. NO. NO. � CITY ZIP TEL. UNITS STORIES _ BEDROOMS , � DESCRIF'TION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OWNER-BUILDER DECLARATION SFR/ADD/HEM � I HEREBY AFFlRM UNDER PENALiV OF PEPJURV THAT 1 AA1 E%EMPT FROM THE COMRACTORS LI- Gef89B/C91pOfI W CENSEUWfOflTNEFOILOWINQREA50N(SEC.70.91.SBUSINESSANOPROFESSIONSCODE:ANYCITYOR (n U COUNTYVRIICMREWIRESAPFAMITTOCONSTHUCT,ALTEH.IMPROVE.DEMOLISH,ORREPAIRANYSTRIIC- w iUP.E,PRIOR TO ITS ISSUANCE,ALSO REO�IRES THE AVPLICANT FOR SUCH PERMIT TO FILE A SIGNED w P8I10/DBCk � S7ATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIqVS OF TNE CONTRAC70R5 LI� � � CENSELAW(pU1PTERe[COMMENCINOWfTHSECTIaN7000)OFDIVISION30FTHEBUSINESSPNDPfl0. POOUSpB FESSION3CADE)ORTHATHEORSHEISEXEMP77NEREFROMANDiHEBASISFOP7HEAlLEGEUF.%EMP- � V TqN.�NYV10UTIp�OFSECTION7Q91.58YANYAPPLICANfFORAPERMIT5U8JECT5THEAPPLICANTTO Z Re-Roat � �CML PENRLiY OF NOT MOpE THAN FNE HUNDREO OOI.URS(550%.): � ❑I.ASONMEROFTHEPROPF.RTV,ORMYEMPLOYEESWITHWAGESASTHEIRSOLECOMFENSATION, CommBfCial WILL DO THE WORK�0 THE BTRUCNpE IS NOT INIENDED OR OFFEflED FOR Sh!E(SEC.7on4,BU31- � y NESS AND PROFESSIONS CODE:THE CCKfFlACTOqS LICENSE LAW DOES NOT APPLY 70 pW OWNER OF PIqPEflTYWNOBU1lD50RIMPqOVESTHEREON,ANDWHODOESSl1CHWORKHIMSFIFORHERSELFDH � W7HFi0U0HH130RHERONMEMPLOVEES,PROVIDEOTHATSUCHIMPROVFMENTSARENOTIN7EN0EDOR m Q OFFEflEDFOR9ALEIP,HOWEVERIMEBUIIAMGORIMPROVEMENTI550LDWITMINONEYEAPOFCOM%.E , Z TqN,TME ONMEHAUI�DER WILL HAVE THE BURDEN OF PROVING THAT HE OR SNE DI�NOT BUILD OR � IMPROVEWRTHEPUHPOSEOFSALE). t �y,� III,ASOWNEHOFIHEPROPERTY,AME%CLU91YElYCONTRACTINGWITIILICENSEDWNTRACTORS ¢ TO GONSTRUCTTHE PHOJECT(SEC.7049,9USINE35 AND PROFESSIONS CADE:THE CONTRACTORS Lb VelUeti0fl ADJ.AREA LLl CENSELAWOOESNOTR7VLVTOANOWNEROFAPROPERTYWHOBUILDSORIMPROVESTHEPEON,ANO --" '------'— --- — '� WFpCONTMCTSFOqSUCHPRQIECTSWITHACONTRACTOH(9)IICEN3EDPURSUMRTOTHEGONTqAG �E � TORSLICENSEUW.j. QUANTIN DESCRIPTION 111 O ���IXEMPT UNOER SEC. ____B.6 P.C.FOH TMI5 REASON Q � }� U — LL � '� Z DATE_ OWNEH ___ � A � LICENSED CONTRACTORS DECLARATION W � � I HEflEBY�FFIRM UNDER PENALN OP PERJURY iHAT IAM LICENSFO UN�ER PROVISIONS OF CHAP7ER �r & ���' N�: 1�; G C�.� � ,, �.� � 9�COIAMENCINOWITHSECTqN7oao)OFDIVISION30F7HEBUSINESSANDPqOFFSSIONSCODE,AND Z �� MY UCENSE IS M FULI.FORCE nAND EFFEC7, //� m � LICENSE CLASS �` �/� LIC.NO. tl!C\'�1 \�� � , —Y1.�(�c �('�i_L—'—_----_ J WppTE �1�(:,• ��''`"\Lf CONTHACTOHY.:A lh�},�1�i �_�f':� � � WORKERS'COMPENSATION DECLARATION � NI HEREBY qFFIRM UNDEF PENPLiY OF PERJURY ONEOFTHE FOLLOWINR DECLARATIOYS: Z o _.__IHAVEANDWILLMAINTAINACERTIFICATEOFCONSEN7TOSELF�INSUqEFOfiWORKEF9' _ � COMPENSATION.ASPROVIDEDBYSECTION37o00FTHELABORCODE,fORTHEPEHFORMANCE W n g OF THE WORK FOR WHICH THIS PF.RMIT IS ISSUED. � A � '. �.___"_-___'__" � Q _�_i HAVEAND WILL MIAINTAIN WORNERS'COMPENS�TION INSURANCE,AS REOUIRED BY SECTION 37000FTHElABORCODE,FOR7HEPERFORMANCEOF7HEWORKFOHWHICHTFIISPEHMITIS _ ISSUED.MYWORKERS'COMPENSATKKJINSURANCECARRIERANDPOUCYNUMBERARE: CONSTflUCTION ____ > CARRIER `•'�=5:����.��- ---- ------....... PUN Aeview --- -- - ---- O �{ /y ' __ _'_ "__..._'__' z POLICYNUM6ER_�"9�4'��Z� . ELECTRIC —_'-'_— __ - ¢ "'—""' y—'" — ' � (iH5SEC7i0NNEmNDTBEOqAPLEfEDOFTFEPEFUMISFORONEFNrDREDCOIiNiS�SIOo)ORLESS} PLLIMBING ..,_____' e,��_,_QS — Z ICERiIFYTHATINTHEPERFORMANCEOFTHEWORKFORWNICHTNISPE9MITI515511ED,1 MECHANICAL _ C.�S SHALLNOTEMPLOYANYPERSONINANYMANNEHSOASTOBECOMESUBJfCTTOTfIf: �� (n WORKERS'COMPENSATIONUWSOFCALIFOFNIA,AN�AGREETHATIFISHOULDBECAME INSPECTIONFEE _._,_,_ - SU&IECTTOTHEWORKERS'COMPENSATIONPROVISIONSOFSECTION37uoOFTHELA90R . •-^ � COOE,ISHALLFORTHWIhICOMPLYWITiiH SEPROVISIONS. ISSIIANCE H O ('�� (�C� /�s� "__ "'"" '_"- , , r p �ATE:�]1J��'`�O APPLICANT. /� „�'-�.C'--� __. SMIP _—__ __....___ .._._..__ J WAHNINGFAILURETOSECUFEWOFKEF5'CAMPENSATIONCOVEflAGEISUNLAWFUL.ANDSHALL9E ENERGYP/C _.,._________. _ LL SlJ&IECTANEMPLOY[HTOCRIMINALPENALTIESANDCIVILFINESUPTOONEHUNDflEDTHOUSAN� ENERGYPERMIT DOUARS(5700.000),IN RDOITIONTO THE COSTOF CAMPENSAYION,DML�GESAS VHOVIDED FOR IN -- - ..___.._..._..__....._ __ ¢ 5[CTION37080FTHEU�BORCODE,INTEREST,ANDATTORNEY'SFF.ES RETENTIONFEE: ' � OCONSTRUCTION LENDING AGENCY PRE-AlT FEE: _.__._ _ _ � I HEREBYAFFIRM UNDEfl PENAL7V DF P[HJUflY THAT 7HERE IS A CONSTRUCTION I.EN�MG AGENCY __ __ _ FOR THE PERWRMqNCE OF THE WORN FOii NRiICfI THIS PFRMIT IS ISSUED�SEC.309�,CIV.G.�, Z w -- —'- —_'_ � LENDER'SNAME_____ - -- _"___'__'_... F- IENDEWSADDRE55_ _.._..._'_—_ .______.'_' w ICERTIFYTHATIHAVEflEADTHISAPPLICATIONPNDSTATETHATTHEABOVEINFOpMATKKJISCORRECT. TOTAL FEES � �� , �� � IAGfiEETOCAMPLYWITHALlCI7YANOCOUNTVORDINANCESANDSTATELAWSRELATINGTOBUILDING �� � CONSTHUCTION,ANO HEHEBY AUTNORIZE REPiiFS[NTATIVES OF TH�S COUNIY TO ENTERUPON THE Z A00VE-61ENTIONEO PHOPER7V FOR INSPECTION PURPOSES. � COMMENTS,_ _______.___,_.___ _ __ � L"'_(G�'�^—� —'--- --'— -- m PE{iMITTEENMIE(PRIFlT) � Cn ���//_S _-_ '__— '—_ '_' � SKiNATUREOFPERMITTEE DATE = RECPT.NO. PAID BY VALIDATIO ~ WHITE-0e artment Co YELLOW--Finance Co PINK—Assessor Co GOLDENRO�File Co GREEN—A icanfs Co P PY� PY� PY. PY. Pf�� PY _.. � ._ .. ._ _ _... .... �� i ; � ; .. . _... _ .. .... _ . ... __ _ , � - - ; �s � ' . . � ' � ' � � i � � ' , � � j : ' i ; ' . ' i' ; �F Y M5 +� . � , I i . � i . _ I � I . ' i . i ' i ��j`, i `. . I � I . - � � I � � i � � . � y �ls � _ ! . , i - - - . � � ' � . 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